1639331325 NPI number — ELIZABETH MARIE EVERETT P.A.-C

Table of content: ELIZABETH MARIE EVERETT P.A.-C (NPI 1639331325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639331325 NPI number — ELIZABETH MARIE EVERETT P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVERETT
Provider First Name:
ELIZABETH
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEEKER
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639331325
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12221 MERIT DR
Provider Second Line Business Mailing Address:
STE 1610
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75251-2202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-217-1911
Provider Business Mailing Address Fax Number:
214-217-1912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12221 MERIT DR
Provider Second Line Business Practice Location Address:
STE 1610
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75251-2202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-217-1911
Provider Business Practice Location Address Fax Number:
214-217-1912
Provider Enumeration Date:
06/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA05805 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 280829701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 280829703 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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